Glossary for an Online Health System

A patient's ability to obtain medical care, which is a function of the availability of healthcare services and cost.

Ambulatory care :

is any medical care delivered on an outpatient basis.

ASP (Applications Service Provider):

Application service provider is a business that provides computer based services to customers over a network.

Authentication:

The verification of the identity of a person or process for purposes of accessing medical records, whether they are stored on paper or digitally. In the case of computerized systems, this typically involves entering a combination of account numbers and passwords or other personal information so that the identity of the person using the computer is verified and access can be enabled.

Short for Web browser, a software application used to locate and display Web pages.

CMS: Centers for Medicare and Medicaid Services :

The Centers for Medicare and Medicaid Services is a federal agency within the U.S. Department of Health and Human Services which is responsible for administering Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), HIPAA and CLIA. CMS is responsible for oversight of HIPAA security standards.

Chart :

A medical record .

Chart Note:

A document, written by a health care provider, which describes the details of a patient's encounter. Sometimes referred to as a progress note. .

Claim:

A request by an individual (or his or her provider) to that individualÃ¢ÂÂs insurance company to pay for healthcare services.

Claims Review:

Healthcare claims are reviewed prior to reimbursement by an insurer.

Computerized Patient Record (CPR):

Also known as an EMR or EHR. A patient's past, present, and future clinical data stored in a server.

Computerized Physician Order Entry (CPOE):

A system for physicians to electronically order labs, imaging and prescriptions .

CPT Code:

A nationally recognizable five-digit number used to represent a service provided by a healthcare provider.

CCR:

Continuity of Care Record. The continuity of care record is a standardized electronic snapshot of a patientÃ¢ÂÂs medical, insurance, and demographic information at any given point in time. While not all of the patientÃ¢ÂÂs information is in the CCR, critical information is available that may be useful in referrals and emergencies.

Dashboard:

The dashboard of an EHR refers to main screen of the software where short links of all necessary modules are given for quick access of records.

Data Integrity:

Refers to the validity of data. A condition in which data has not been altered or destroyed in an unauthorized manner.

Database:

A collection of information organized in such a way that a computer program can quickly select desired pieces of data.

Dictation:

The process by which a physician records his/her notes about a patient. This recording is intended for reproduction in written word (Transcription).

Digital Imaging and Communications in Medicine (DICOM):

A standard to define the connectivity and communication between medical imaging devices.

Digital Signature:

Sometimes referred to as Advanced Electronic Signature. Digital signature takes the traditional hand-written signature and creates a digital image of the signature to eliminate the need to print and sign documents.

Document Imaging:

Converting paper documents into an electronic format, typically through a scanning process.

Drug Formulary Database:

this EMR feature is used for electronic prescribing, electronic medical record (EMR), and computerized physician order entry (CPOE) systems to present formulary status to the provider during the prescribing decision.

Documentation:

The process of recording information.

Document Management:

A system involving scanning, categorizing and storing vital patient documents.

Drug Formulary:

Lists of prescription drugs approved by a given health insurer. Health plans often restrict or limit the type and number of medicines allowed for full or partial reimbursement.

Encryption:

Process of converting messages or data into a form that cannot be read without decrypting or deciphering it. DES is one such commonly used system. Encryption allows sharing of sensitive or confidential information over the Internet with authorized users with a high degree of security. Encrypting sensitive data for transmission is considered by many now to be a standard component of ensuring HIPAA compliance.

e-Prescribing:

Prescribing medication through computerized systems and transmitting the information electronically to participating pharmacies. It also enables health care providers and pharmacies to share information about a patientÃ¢ÂÂs insurance eligibility and medication history.

E/M level coding:

Evaluation and Management level coding Ã¢ÂÂ documentation of each visit which identifies each service provided during an office visit.

EMR:

Acronym for Electronic Medical Records. A computerized record of a patient's clinical, demographic and administrative data. Also known as a computer-based patient record (CPR) or electronic health record (EHR).

Electronic Health Records (EHR):

Patient health records including treatment history, medical test reports, and images stored in an electronic format that can be accessed by healthcare providers on a computer network.

Explanation of Benefits (EOB):

A statement from the patient's insurance company that breaks down services rendered at time of doctor or hospital visit and amounts covered by insurance provider.

Group Practice:

A group of persons licensed to practice medicine who share common overhead expenses, medical and other records, equipment, and professional staff.

Growth Chart:

A feature for EMR. Age, height, weight, and head measurements can be entered over the patient's lifetime, and the feature creates a line graph.

HIPAA:

The Health Insurance Portability and Accountability Act of 1996, is a set of federal regulations which establishes national standards for health care information.

Hybrid Record:

A providerÃ¢ÂÂs use of a combination of paper and electronic medical records during the transition phase to EMR.

ICD-9:

Internationally recognizable 3 to 5-digit code representing a medical diagnosis. Currently being replaced by the ICD-10 code.

Interoperability:

The capability to provide successful communication between end-users across a mixed environment of different computer domains and networks, facilities, and enterprises. Typically used in referring to a long term goal of allowing interoperability, or easy exchange, of information between different electronic medical records systems.

Immunization Records:

A vaccination that induces immunity. A recommended schedule of immunizations for infants and young children includes vaccines against diphtheria, polio, tetanus, measles, mumps, and rubella. Immunization records refer to vaccines record in an EHR given to the patients.

Basic or general health care usually rendered by general practitioners, family practitioners, internists, obstetricians and pediatricians who are often referred to as primary care practitioners or PCPs.

Privacy:

For purposes of the HIPAA Privacy Rule, privacy means an individualÃ¢ÂÂs interest in limiting who has access to personal health care information.

Problem List:

Basic or general health care usually rendered by general practitioners, family practitioners, internists, obstetricians and pediatricians who are often referred to as primary care practitioners or PCPs.

Protocols:

Healthcare provider guidelines governing the specific medical care to be delivered for each disease or medical diagnosis.

Referral:

Most health insurers require a referral by the individualâs Primary Care Physician for certain procedures or visits to specialists.

Remote Access:

Data travels through a private, protected passage via the Internet, allowing healthcare providers to access from home or another practice location and allows EMR vendor to perform system maintenance off-site.

Scheduler:

A program that arranges jobs or a computer's operations into an appropriate sequence. Patient scheduler helps in creating scheduled appointments. A provider can schedule appointments for future days as well and can manage the work more effectively.

Subscriber:

Person responsible for payment of premiums, or person whose employment is the basis for membership in a health plan.

SureScripts:

Electronic exchange that links pharmacies and healthcare providers. Founded in 2001 by NACDS to make the prescribing process safer and more efficient.

SOAP:

A commonly used format for medical documentation which helps to organize the information. SOAP is an acronym for S-Subjective, O-Objective, A-Assessment, P-Plan.

Transcription:

The process by which medical transcriptionists convert physicianâs dictation into written (typed) words.

Treatment:

The provision of health care for an individual. HIPAA provides for the use and sharing of protected health information for treatment purposes without authorization.

vital signs:

Clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient.

Workflow:

The specification or the automation of a work process during which documents, information or tasks are passed from one participant or system to another for action, according to a set of standardized rules.